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Retrospective review

Retrospective review is the process of determining coverage after treatment has been given. These evaluations occur by:

 

  • Confirming member eligibility and the availability of benefits
  • Analyzing patient care data to support the coverage determination process
  • Receiving supporting clinical documentation from providers with the payment request

Retrospective review is available when:

 

  • Precertification/notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim.
  • Aetna converts from secondary payer to primary payer at the time of inpatient claims adjudication.

Retrospective review is not available when claims are for:

 

  • Elective ambulatory or inpatient services on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List for which precertification did not occur before providing the service
  • Emergency inpatient services on the previously mentioned precertification lists that did not meet notification requirements (notification of inpatient admissions is required within one business day of the admission date)
  • Services not included on a precertification list
  • Services that do not require precertification under the terms of a member’s plan

Find precertification lists

The retrospective review process includes:

 

  • The identification and referral of members, when appropriate, to covered specialty programs, including Aetna Health Connections case management and disease management, behavioral health, National Medical Excellence Program®, and women’s health programs, such as the Beginning Right® Maternity Program and the infertility program.
  • The identification and referral of potential quality and/or utilization issues for follow-up
  • The identification, referral and review (as applicable) of patient safety events

Retrospective review does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider.

 

Note: More stringent state requirements may supersede the requirements of these policies.

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Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.